Citation Nr: 0028563
Decision Date: 10/30/00 Archive Date: 11/03/00
DOCKET NO. 95-06 428 ) DATE
)
)
On appeal from the
Department of Veterans Affairs Regional Office in Atlanta,
Georgia
THE ISSUE
Entitlement to service connection for post-traumatic stress
disorder.
Entitlement to service connection for schizophrenia, paranoid
type.
REPRESENTATION
Appellant represented by: M. K. Hart, Attorney
ATTORNEY FOR THE BOARD
R. K. ErkenBrack, Counsel
INTRODUCTION
The veteran served on active duty from November 1992 to
February 1993.
This appeal comes to the Board of Veterans' Appeals (Board)
from a January 1997 rating decision of the Department of
Veterans Affairs (VA) Regional Office (RO) at Atlanta,
Georgia.
The case was remanded by the Board in September 1997 for
additional medical clarification and evidence concerning the
diagnosis and the etiology of the veteran's psychiatric
disorder. The purpose of the remand has been met.
FINDINGS OF FACT
1. A preponderance of the evidence shows that the veteran
does not have post-traumatic stress disorder.
2. Paranoid type schizophrenia is shown to have had its
inception during active service.
CONCLUSIONS OF LAW
1. Post-traumatic stress disorder was not incurred in or
aggravated by service. 38 U.S.C.A. §§ 1110, 5107(a) (West
1991); 38 C.F.R. §§ 3.303 (1999).
2. Schizophrenia, paranoid type, was incurred in service.
38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107(a) (West 1991);
38 C.F.R. §§ 3.303, 3.307, 3.309 (1999).
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The service and postservice medical records are presented to
show whether or not the veteran had post-traumatic stress
disorder or any other chronic psychiatric disorder during
active service or whether such is currently shown to be
traceable to active service. The symptoms or manifestations
on the various examinations are presented to identify the
basis for the diagnoses of her psychiatric disorders.
The service medical records include no complaint, finding or
diagnosis of any psychiatric abnormality.
On a VA examination in September 1994, the veteran gave a
history that she had been discharged from the Army after
approximately 90 days of active duty for a combination of
health and personality problems. She was hospitalized for
respiratory problems in early February 1993. She was
depressed. She had recently lost her job as a substitute
teacher even though she had a Master's Degree. There was no
psychiatric evaluation or diagnosis.
An October 1994 report from the Army's Board for Correction
of Military Records showed that the veteran entered active
service on December 1, 1992 and began receiving counseling
statements for disrespect, low training scores, inability to
maintain standards of personal appearance, lack of motivation
and disobeying an order on January 5, 1993. On February 4,
1993, her unit commander wrote a counseling statement to the
veteran that she should be separated for unsatisfactory
performance and conduct. When given the opportunity to
respond, she requested to remain on active duty and be given
the opportunity to become a good soldier. Nevertheless, her
commander's request was approved and she was administratively
discharged. She had had 3 months and one day of creditable
service.
VA outpatient treatment records show that the veteran was
seen in April 1995 with increased symptoms of depression,
imminent unemployment and a history of a suicide attempt
during a previous period of forced unemployment under similar
conditions. Major depression was to be ruled-out. She was
referred for VA hospitalization in a suicidal state a few
days later. She had lost her job and had trouble sleeping,
anergia, a depressed mood and was homeless. She wanted to
jump in front of a bus. Major depression was diagnosed.
Another psychiatric evaluation in May 1995 reflected the
diagnosis of major depression without a psychosis. She
complained of having been depressed for a year since she had
lost a job.
Private clinical records show that the veteran was seen in
April 1995 for complaints of depression because her boss was
trying to fire her. She was planning on committing suicide
by jumping in front of a bus. She also was having severe
problems sleeping. A history of a suicide attempt by drug
overdose a year
previously when she lost her job was noted. She felt
responsible for her mother's death. She did not talk with
any family members. She reportedly had only one friend.
Major depression, recurrent, was diagnosed. In August 1995,
she reportedly felt angry and stupid. She reportedly had
been crying at work and unable to control herself. She
described forgetting things at the grocery store and
forgetting appointments. Her problems concentrating were
related to thinking about her mother's death and getting
depressed. She had trouble finishing things due to fatigue.
She sometimes found it difficult to get out of bed. She
wanted to be alone and isolated from everyone.
A private examination conducted for Social Security purposes
in October 1995 reflected a history that the veteran was
doing well until her mother's death in October 1994, after
which she became severely depressed and suicidal. She had
failed at a job. Her depression continued because she was
worried about being out of work and was nearly homeless,
living in a boarding house and barely paying her rent from
month to month. Dread, depression, fear and anxiety
reportedly ruled her life. She felt unable to cope with
things and wondered if she had any future. She was
chronically sad and broke down weeping on several occasions
during the examination. The impressions included major
depressive disorder starting with traumatic events in her
life the previous spring and winter. The examiner commented
that the only important problem for the veteran was
psychiatric, due to depression, which possibly was mainly
reactive. She was being followed regularly by a
psychiatrist. She was described as probably well suited to
high level employment once her psychiatric problems were
dealt with properly.
During the course of a personal hearing on an appeal for
service connection for a respiratory disorder in November
1995, the veteran testified that, after inservice gas chamber
training, she suffered from vomiting and burning lungs. When
she asked to go to the hospital, her drill sergeants
reportedly laughed and told her that she would be all right.
She continued to experience lung problems but her superiors
did not believe her and reportedly followed her to sick call
and told the doctor there that she was lying or malingering.
Even when she needed to go to the hospital for her illness
during active service, she felt that if the drill sergeants
had had their way she would have been somewhere else, sick
and miserable. On one occasion in the hospital she testified
that one of her drill sergeants came in and placed a pillow
over her face when she was sleeping. When she awakened,
struggling, he reportedly told her that he was just kidding.
She felt that he had done that to "rattle her cage." She
submitted a sworn statement at the hearing that she
experienced depression and suicidal tendencies. She
reportedly had uncontrollable crying spells. She stated that
she had not been successful in retaining employment because
she lacked concentration and had memory difficulties. She
felt like an outsider and had hardly any friends. She
described herself as alone and isolated. She reportedly had
fits of rage whenever she thought about her treatment by the
Army.
Private outpatient clinical records show that she was seen
for complaints of depression and memory loss in December
1995. She complained of difficulty in performing routine
tasks and an inability to concentrate.
On a VA examination in December 1995, the veteran reported
that she had been attacked during active service once when
her sergeant tried to put a pillow over her face when she had
been in a hospital and another time when her sergeant grabbed
her and she thought that she was going to be pushed down some
steps. She reportedly lived alone on general assistance and
food stamps. She had had jobs teaching at a juvenile
detention center and working for the Internal Revenue Service
but she had lost those jobs because she could not handle her
job responsibilities. She felt that the "military"
followed her around and told all potential employers that she
could not handle a job because she was too sick. She stated
that she saw camouflaged cars following her. She had no
friends and did not know what she was going to do next. She
was found to be depressed, paranoid and delusional. Affect
was flat. Schizophrenia was diagnosed. In the examiner's
opinion, schizophrenia was manifest during the veteran's
military service.
A private psychological evaluation of the veteran in March
1996 in connection with her claim for Social Security
disability benefits showed that she felt that she was
suffering from depression and post-traumatic stress. She
reportedly lived alone in an apartment. She complained of
anxiety centered around a near-death experience during
military service, nightmares, flashbacks involving the
incident, anger, rage at times, depression, difficulty
sleeping, and weight loss. Current stressors were listed as
the inservice near-death experience, her mother's death,
being fired from a job, and a pending law suit concerning the
termination of the job. The mental status examination showed
that she was somewhat paranoid. Her mood was depressed and
consistent with affect. She reported suicidal ideation and
plan but no intent. She described a homicidal ideation
toward those who had fired her but no plan or intent. She
slept all day and her appetite was poor. There was no
evidence of a formal thought disorder. She described
auditory hallucinations of her drill sergeant whispering to
her. These reportedly began after the inservice near-death
experience. She was oriented to person and time but missed
the date, place, county, building or floor of the
examination. She named the city and state. She could name
the current but not the predecessor president. She could not
perform "serial seven's" but could spell "world"
backwards. She recalled two words after 5 minutes. She
tended to work persistently on most items during testing.
Her performance reportedly might have been negatively
affected by psychomotor slowing. The results of the
evaluation were considered by the examiners to underestimate
her psychological functioning. She was not judged to be
overtly malingering or exaggerating her symptoms. The final
diagnoses were post-traumatic stress disorder and paranoid
personality disorder.
The examiners' summary and prognosis in March 1996 showed
that the veteran's level of functioning was far below what
would be expected based on her education and work history.
This was possibly attributable to anxiety, psychomotor
slowing and the intensity of stressors. Her symptoms
reportedly were consistent with post-traumatic stress
disorder from a near death experience in the service (on
which she did not care to elaborate) and other symptoms
exemplified by auditory hallucinations and depressive
symptoms were considered secondary to post-traumatic stress
disorder. She also exhibited a good bit of paranoia. Her
prognosis for employment was termed fair.
On a VA examination in August 1996, the veteran reportedly
had difficulty entering into a coherent conversation and she
frequently punctuated her remarks with profane words. She
seemed angry and upset. She was guarded and cautious. She
stated that "they tried to kill me" during active service.
She recounted that she
could not breathe after gas chamber training. She felt that
"they" were still trying to kill her and that "they" had
ruined her life. She felt that she could not get a job
because "they" had poisoned everyone against her. She
stated that the military had sent people after her when she
moved. She reportedly had seen them on the street and
"they" were trying to get her hooked on drugs. She
reportedly had attained a Master's degree in education and
stated that "they" were jealous of her in the Army because
"they" knew that she had more education than "they." She
complained that she did not have an appetite. She did not
sleep. She had not been able to get a job. She was unable
to explain how she was managing. She felt that there was a
drill sergeant "out there" who was trying to get her in
trouble and who she believed had been ordered to kill her.
Her thought processes were scattered,. She was delusional
and hallucinatory. Affect was flat and depressed. Paranoid
schizophrenia was diagnosed. The diagnosis also reflected
that post-traumatic stress disorder was not found.
An award of Social Security disability benefits in July 1997
reflected the veteran's history of recurrent major depression
in April 1995 with a previous attempt and ongoing plan for
suicide. Post-traumatic stress disorder and a paranoid
personality reportedly had been diagnosed in March 1996.
A VA psychiatrist reported in December 1997 that, after
review of the claims file and, in particular, the August 1996
examination, the veteran was clearly a schizophrenic and as
reliable as she could be in terms of her paranoid beliefs.
The opinion of the examiner was that schizophrenia was
manifest during service.
The same VA psychiatrist reported in October 1998 that the
veteran's case was clearly one of schizophrenia without
evidence of a post-traumatic stress disorder.
On a VA examination in December 1999, history was recorded
from the veteran that she started to hear voices during
active service and thought that the drill instructors were
playing games with her. There reportedly was a note that her
discharge from the service was recommended for disrespect,
inability to maintain personal appearance, lack of
motivation, and disobeying an order. She reportedly
saw a psychiatrist seven months following active service for
counseling. She stated that she was first on medication in
1994 when she was hospitalized by VA for major depression.
She thought that she was placed on anti-psychotic medication
for the first time in 1994. She resided in a group home.
She was unemployed. She complained of being upset that she
was still not in the service. She felt that, if she had not
been sexually harassed, she would have liked to remain on
active duty. She was bothered by auditory and visual
hallucinations of voices calling her name and arguing. She
felt depressed at times. When she felt stress, she had
difficulty with anxiety. She related that she no longer had
any hobbies. The objective findings showed that she would
not elaborate on her military experience beyond saying that
she had been sexually harassed and experienced
hallucinations. She actively hallucinated and verbally
responded to hearing a voice. She stated that the voices she
heard commanded her at times to cross the street or to hurt
herself. She also stated that she had visual hallucinations
of the people whose voices she heard. She admitted to
paranoia and being uncomfortable around people. She stated
that at times she got depressed. There was no evidence of
suicidal or homicidal ideations or panic attacks. There was
evidence of some anxiety. She was grossly intact,
cognitively. She had attempted suicide twice.
Schizophrenia, paranoid type, was diagnosed.
The examiner discussed that the veteran clearly met the
diagnosis for schizophrenia, paranoid type. There reportedly
was no evidence of post-traumatic stress disorder.
It was felt that the claim of sexual harassment against the
drill instructor was all part of the psychotic thought
processes related to her schizophrenia. She stated that she
was hearing voices during active service, which reportedly
might have been one of the earliest symptoms of
schizophrenia. With respect to when schizophrenia started,
there was no evidence that she sought treatment by a
psychiatrist during active service, but she stated that she
was hearing voices and it was suspected that her mental
problems might have led to the situation that ultimately
caused her discharge. It was stated that schizophrenics
frequently do not keep up with their personal appearance, and
they display a lack of motivation, etc. It was felt that
some of the reasons she was discharged from the service might
have had their precipitating cause in the schizophrenia which
was not diagnosed at that time. It
reportedly appeared that she had been misdiagnosed or was not
displaying full blown symptoms for some time, however, there
was no question that she was a schizophrenic. She clearly
had a decreased level of functioning. Someone who had the
veteran's level of work in college who entered active duty
nine months later and had to be discharged after three months
was described as clearly showing a deteriorating level of
function, which would be consistent with schizophrenia. She
was actively psychotic and clearly could not maintain gainful
employment.
A well-grounded claim for service connection generally
requires medical evidence of a current disability; evidence
of incurrence or aggravation of a disease or injury in
service as provided by either lay or medical evidence, as the
situation dictates; and, a nexus, or link, between the
inservice disease or injury and the current disability as
provided by competent medical evidence. Cohen v. Brown, 10
Vet. App. 128, 137 (1997); Caluza v. Brown, 7 Vet. App. 498
(1995) aff'd per curiam, 78 F.3d 604 (Fed.Cir. 1996) (table);
see also 38 U.S.C.A. §§ 1110; 38 C.F.R. § 3.303; Layno v.
Brown, 6 Vet. App. 465 (1994); Espiritu v. Derwinski, 2 Vet.
App. 492 (1992). Alternatively, the nexus between service
and the current disability can be satisfied by evidence of
continuity of symptomatology and medical or, in certain
circumstances, lay evidence of a nexus between the present
disability and the symptomatology. See Savage v. Gober, 10
Vet. App. 488, 495 (1997). Establishing direct service
connection for a disability that was not clearly present in
service requires the existence of a current disability and a
relationship or connection between that disability and a
disease contracted or an injury sustained during service.
Cuevas v. Principi, 3 Vet. App. 542 (1992); Rabideau v.
Derwinski, 2 Vet. App. 141 (1992). With a chronic disease
such as a psychosis, service connection may be granted when
the disease is manifested to a compensable degree within one
year following service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38
C.F.R. §§ 3.307, 3.309(a).
Moreover, establishing a well-grounded claim for service
connection for a particular disability requires more than an
allegation that the particular disability had its onset in
service. It requires evidence relevant to the requirements
for service connection cited above and of sufficient weight
to make the claim plausible and
capable of substantiation. Tirpak v. Derwinski, 2 Vet. App.
609 (1992); see also Murphy, 1 Vet. App. at 81. The kind of
evidence needed to make a claim well grounded depends upon
the types of issues presented by the claim. Grottveit v.
Brown, 5 Vet. App. 91, 92-93 (1993). For some factual
issues, competent lay evidence may be sufficient. However,
where the claim involves issues of medical fact, such as
medical causation or medical diagnoses, competent medical
evidence is required. Grottveit, 5 Vet. App. at 93.
The veteran has not claimed that her psychiatric disorder
arose under combat conditions. Thus, entitlement to
application of 38 U.S.C.A. § 1154(b) is not warranted.
The Board has determined that the veteran's claim for service
connection for a psychiatric disorder, to include
schizophrenia and post-traumatic stress disorder, is well
grounded. The appellant is competent to report that she
experienced trauma during active service. There is also
competent inservice evidence that she was discharged for
unsatisfactory performance that included disrespect, low
training scores, inability to maintain standards of personal
appearance, lack of motivation and disobeying an order.
Subsequently dated clinical evidence links post-traumatic
stress disorder to inservice trauma and schizophrenia to
inservice displays of unsatisfactory performance.
With respect to post-traumatic stress disorder, the Board
finds that the preponderance of the evidence is against the
current presence of this diagnosis. Without a present
disability, it is obvious that service connection for it
cannot be granted. Post-traumatic stress disorder was first
diagnosed on the private psychological evaluation in March
1996. This was related by the examiner to an inservice
"near-death" experience. Nevertheless, exhaustive
psychiatric evaluations before and since that examination
either do not reveal post-traumatic stress disorder or, more
significantly, rule it out. The VA psychiatric evaluations
in 1995 did not reveal post-traumatic stress disorder, even
though the history presented by her of inservice traumatic
episodes was considered. The VA psychiatric examination in
August 1996 specifically ruled out the presence of post-
traumatic stress disorder
even though her history of attempts on her life during active
service were recorded. A VA psychiatric opinion in October
1998 specified the absence of evidence of post-traumatic
stress disorder. Conclusively, the VA examination in
December 1999 ruled out the diagnosis of post-traumatic
stress disorder. In summary, the Board finds that the
preponderance of this medical evidence establishes that post-
traumatic stress disorder is not present and, thus, cannot be
service connected.
With respect to paranoid type schizophrenia, the Board finds
that most of the clinical evidence supports the conclusion
that it, more likely than not, is traceable to active
service. Service medical records are silent on this matter,
but the reasons for the veteran's administrative discharge
from active service involve behavioral problems. Personality
problems connected with her separation from active service
were reported on the first VA examination in September 1994.
Major depression with suicidal ideation and plans was first
diagnosed in 1995. The November 1995 testimony linked the
symptoms of depression and suicidal ideation to her inservice
experiences. The VA examinations beginning in December 1995
linked schizophrenia to the inservice experiences she
reported suffering at the hands of her drill instructors.
Her paranoid ideas had to do with military figures following
her around making statements against her to employers. The
psychological report in March 1996 did involve the diagnosis
of post-traumatic stress disorder but also linked auditory
hallucinations and depression to inservice experiences. The
August 1996 examination involved symptoms traced to service
regarding her feelings that her drill sergeants had tried to
kill her and continued to act against her. Her VA examiner
reported in December 1997 and October 1998 that schizophrenia
was manifested during active service. Conclusively, the VA
examination in December 1999 establishes the connection
between present day schizophrenia and inservice reports of
sexual harassment, auditory hallucinations, and the reasons
for administrative discharge of lack of motivation and
inability to maintains standards of personal appearance.
While that examination did not present this linkage with
certainty, the Board finds that, on balance, the evidence for
the connection outweighs the evidence against the connection.
Accordingly, the requirements of service connection for
paranoid type schizophrenia are met.
ORDER
Service connection for post-traumatic stress disorder is
denied.
Service connection for schizophrenia, paranoid type, is
granted.
CLIFFORD R. OLSON
Acting Veterans Law Judge
Board of Veterans' Appeals
as